A diagnosis of infertility is made when a man and woman have unprotected intercourse for one year without resulting in pregnancy, or for six months if the woman is older than 35 years of age. The cause of this lack of conception can be due to either the male or female partner, or a combination of the two. Both men and women suffer from infertility equally.
Infertility is not synonymous with sterility (the inability to have children). While 15% of couples in the United States are infertile, only 1-2% is sterile. Up to 50% of couples seeking medical assistance for infertility correction go on to become pregnant.
For women, causes of infertility are:
- Hormonal imbalance
- Thyroid dysfunction
- Pituitary dysfunction
- Conditions causing lack of ovulation
- Polycystic ovaries
- Significantly underweight
- Blockage of fallopian tubes
- Prior surgery with scar tissue
- Prior tubal ligation
- Prior pelvic infection disease (PID)
- Uterine abnormalities
- Septum (wall in uterus from embryo development)
- Adhesions (scar tissue)
- Prior intrauterine device (IUD)
- Prior endometritis (infection)
- Eating disorders
For men, the four most common causes of infertility are:
- Low sperm count (or lack of sperm)
- Low sperm motility – sperm don’t swim as well as necessary
- Sperm malformation
- Sperm duct blockage, making sperm unavailable
Doctors Who Treat Infertility
Often, the general practitioner or family doctor is the first healthcare provider that a woman approaches about her fear of infertility for evaluation and answers to questions. The general practitioner is a physician who treats both acute and chronic conditions for patients of all ages and also provides preventive care.
Additional specialists that provide care are listed below in this infertility patient education guide include:
Gynecologist – a physician who specializes in the sexual and reproductive anatomy of the female and its functioning
Endocrinologist – a physician who deals with the health, diagnosis, and treatment of hormonal system disorders such as thyroid imbalances, diabetes, and pituitary problems (a hormonal imbalance can cause irregular or no menstrual cycles and irregular ovulation)
Infertility Specialist – also known as a reproductive endocrinologist; maintains health and treats reproductive disorders for both men and women
Urologist – a physician who deals with the health and disorders of the male and female urinary tract, as well as male fertility
Psychologist – provides therapy for individuals through counseling and psychotherapy; devises techniques for controlling stress or mood problems (infertility often is accompanied by feelings of anxiety, guilt, and frustration)
Psychiatrist – a medical doctor who focuses on health and disorders of the mind and mood; may prescribe medications in addition to psychotherapy if imbalances or mental disorders are diagnosed
Nurse Practitioner – focuses on prevention, wellness, and education of patients about health and health choices
Nutritionist – a professional who formulates diet plans for both healthy and compromised individuals, as well as advises which vitamins and supplements would promote good health (nutritional status strongly affects fertility and certain supplements can help improve it
Holistic Practitioner – views the body overall, considering physical, mental, and spiritual components; considers herbs and nutritional supplements in addition to meditation, cleansing, diet and exercise protocols
How to Prepare for Your Doctor Visit for Infertility
Having made your appointment with a healthcare provider, there are certain actions you can take to maximize the benefit of your doctor visit such as those listed in this infertility patient education guide.
On the day of the consultation with the physician, bring the following:
- A list of past medical conditions and infections
- A list of past surgeries with dates
- A chart of the dates of your last three menses (record on the menses chart all intercourse episodes)
- All recent laboratory test results
- All recent radiological images
Questions to Ask Your Doctor About Infertility
From your initial diagnosis throughout your treatment and care, you will have questions about your condition. This infertility patient education guide lists questions to discuss with the doctor so you can make informed decisions about your condition and care.
Questions About My Diagnosis
- What is my prognosis? Is this problem permanent or treatable?
- Is my infertility associated with other medical problems?
- Are there tests to confirm the diagnosis of infertility?
- Does my partner need to be tested?
- Will a donor egg or sperm be needed with this diagnosis?
Questions About My Treatment
- What type of treatment do you advise trying first? Why?
- Do I need surgery, drugs, or a combination? What are the risks?
- What is your success rate for the treatment advised? How many cycles would I need to repeat this treatment? Does my insurance cover part or all of this treatment?
- Do you freeze unused embryos? What happens to them?
- Do you advise donor eggs for women after a certain age or amount of failed treatments? What is that age? What is the number of treatments?
Questions About My Lifestyle & Family
- Are there any exercises that I should do to increase my chances of fertility? Are there activities I should avoid?
- Does infertility run in families?
- Is there a diet that you would recommend? Are there vitamins or supplements that I should take?
- Are there alternative therapies that will improve my infertility?
Common Tests or Labs to Diagnose Infertility
The following chart involves testing for women. However, it is crucial that prior to undergoing a complete infertility workup, a thorough physical examination is performed and a history is reviewed. As part of the examination, a pap smear and vaginal cultures are taken. If there is any bacterial infection, viral infection, or sexually transmitted disease, this needs to be treated first and then the issue of infertility can be revisited.
A semen analysis should be performed on the male partner. If there is a deficiency of sperm or sperm motility problems, this needs to be addressed.
|Sedimentation test (ESR)||Indicates:
||After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol pads and a needle punctures the skin. Blood is then drawn into a syringe for analysis.
The test tube that received the blood is assessed in one hour. The more red blood cells that settle into the bottom of the tube, the higher the sedimentation rate and the higher the inflammation.
|Under Age 50
|Hormone tests||Hormone deficiencies can cause a lack of fertility. Also, some hormones, in conjunction with cycle timing, can suggest impending ovulation and fertile periods of time.||After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol pads and a needle punctures the skin. Blood is then drawn into a syringe for analysis.
The needle is removed and a pressure bandage is applied to the puncture site.
Serum thyroxin –T4
Thyroxine-biding globulin- TBG
Thyroid stimulating hormone- TSH
Females 2-29 ng/mL
Pregnant women=10-209 ng/ML
(>10-12 mlu/ml can suggest ovaries are not functioning)
LH Day 3=
Estradiol (E2) Day3
Day 3= <1.5 ng/ml
Day 7 dpo=>15 ng
AMH (anti-mullerian hormone)
Total Testosterone Day 3= 6-86 ng/dL
Day 3= .7-3.6 pg/ml
DHEAS (dehydroepiandro-sterone Sulfate) Day 3= 35-430 ug/dl
Androstenedione Day 3= .7-3.1 ng/ml
Sex Hormone Binding Globulin (SHBG) Day 3=18-114 nmol/l
17 hydroxy-progesterone Day 3= 20-100 ng/dl
Mid-cycle peak =100-250
Free testosterone .95-4.3 ng/dl
Prolactin= <20 ng/ml
|Basal body temperature||Shows if ovulation has taken place and when ovulation and fertile time occurs||Take your temperature daily, first thing in the morning before getting out of bed (with a basal body temperature thermometer) and chart the results.
*Need at least 5 hours of sleep
|Temperature rise of .4 degrees or more in a 48-hour period signifies ovulation. The result should be higher than the prior 6 days.
If there is no change in temperature, no ovulation has taken place.
|Charting cervical mucus||A change in color and consistency reflects ovulation as taking place||To visualize the cervical mucus, you can examine the toilet tissue after wiping or insert two fingers into the vaginal canal and get a little mucus from the cervix.||When mucus snaps with no stretch, it is indicative of no ovulation and not a receptive time.
|Ovulation predictor kit||Looks for the Luteinizing hormone (LH) surge that occurs just before ovulation. The kit will pinpoint the time when you ovulate.||Take a sterile cup, fill with urine, and dip the provided stick inside for 5-20 seconds. Testing will be done on consecutive days for 5-7 days mid-cycle.||The LH surges just before ovulation. If there is no fluctuation in results, ovulation has not occurred or testing needs to be done for a longer period.
|Pelvic sonogram, or ultrasound||Evaluates the structures of the ovaries and pelvic organs for any abnormalities. Follicles can be visualized in the first part of the cycle.||After lying down on the table, the technician places clear water-based gel on your tummy and pelvic area. A hand-held probe is then moved back and forth over the area, transmitting sound waves. The echoes of these waves create an image on a computer monitor.
Sometimes a transvaginal ultrasound is performed. Here, you lie on the exam table with knees bent and feet in stirrups. A covered probe is lubricated and placed in the vagina. The probe emits sound waves and the echoes create an image on a computer monitor.
|Should show no tumors or cysts of the uterus, tubes, or ovaries and no septum, obstructions, or strictures.|
|Hysterosalpingogram (HSG)||Assesses any structural problems within the uterus such as adhesions, septums, fibroids and polyps; detects any obstructions or constrictions of the fallopian tubes||You are placed on the examination table with your knees up and your feet in stirrups.
A speculum is placed into the vagina and a clamp grasps the cervix. A tube is attached to a cap that is placed over the cervix and a contrast dye is infused through the tube. The dye flows up the cervix, uterus, and through the fallopian tubes. X-ray images are obtained as the dye flows, which are impeded if there are any obstructions.
Abdominal or pelvic cramping may be experienced during this procedure and you may be advised to take a mild analgesic prior to the test.
|Should show no strictures or obstructions of the tubes and no growths or impingements on the uterine cavity.|
|Hystero-scopy||Views the uterine lining||You are placed on the exam table with your knees bent and feet in stirrups.
A speculum is placed in the vagina. The tip of the hysteroscope is then inserted through the cervical opening into the uterus.
The hysteroscope has a light and camera attachment so that viewing is done on a monitor or video screen.
|Should show no septum, polyps, or fibroids and no break in integrity of the lining.|
|Post coital test (PK)||Checks to see if the cervical mucus is too thick, if there are sperm antibodies present, and if sperm are moving appropriately|| The couple has intercourse at home at the 12th-15th day of the cycle and comes to the office within an hour.The woman is placed on the examination table with knees up and feet in stirrups.
A speculum (clamp) is inserted into the vaginal vault for visualization of the vagina.
Cervical mucus is aspirated (withdrawn) and placed onto a microscopic slide.
The clamp is then removed.
|Should show thin cervical mucus with no clumping of cells on the microscopic slide.|
Common Medications and Treatments for Infertility
There are several types of therapy when discussing infertility treatments. They center on:
- Stimulation of ovulation
- Hormonal imbalance correction
- Correction of structural obstacles
- Treatment of disease conditions
Treatments can be dietary, medicinal, surgical, or a combination of all three.
Dietary and Lifestyle Treatments
How/Why it Works
|Discontinue tobacco use/exposure to smoke||Cigarette smoke decreases rate of conception; sperm counts are lower and are not as motile|
|Discontinue birth control pills for two cycles||Ovulation may take time to resume regularly.|
|Stress reduction therapies (yoga, meditation, massage)||Ovulation and fertilization are hampered by stress. While the mechanisms are not clearly defined, stress may lead to subtle hormonal imbalances and anovulation.|
|Eat healthy, balanced, and nutritional meals||Studies show that 79% of infertile couples had lowered antioxidant intake (fruits and vegetables are high in antioxidants)
A study published in Archives of Andrology demonstrated sperm’s ability to swim was increased with Vitamin E and selenium.
|Decrease seafood in diet||High blood level of mercury can decrease fertility and cause abnormal semen|
|Decrease weight if obese||Losing 5% body of weight can stimulate ovulation and pregnancy|
|Take daily vitamin supplements||The following vitamin usage has been linked to increased fertility:
|Avoid exposure to pesticides||Exposure has been linked to hormone imbalances (especially estrogen and its receptors)|
|Avoid exposure to marijuana
|Prolactin can increase with drug exposure, causing a lack of ovulation or regular cycles|
|Evaluate current prescribed medications.||Certain drugs will affect success of fertilization or the ensuing pregnancy. Discuss the drugs with your physician. If the drug is not absolutely necessary, discuss discontinuing it and taking alternate means. If the drug is needed, discuss exchanging the medication for one that treats the condition but is not as harmful to the conceptus.|
|Increase time for sleep||Sleep deprivation leads to irregular cycles and decreased ovulation times|
If a hormone imbalance exists due to dysfunction of the thyroid or pituitary gland, medication is given to correct these problems. Until then, anovulation (not ovulating) may present. The following chart is for ways that ovulation may be stimulated outside the scope of a hormonal imbalance.
How/Why it Works
|Clomifene||Selective estrogen receptor modulator (SERM) increases production of gonadotropins by reducing the hypothalamic feedback pathway. This causes ovulation induction.|
|Menotropin (also called human menopausal gonadotropin –HMG)
|Gonadotropins (LH and FSH), which are obtained from postmenopausal women’s urine, are injected to cause multiple follicles in ovulation (stimulating the ovaries) to increase the chances of fertilization.|
|Treatment||How/Why it Works|
|Artificial insemination||Sperm are placed into the cervix, uterus (intrauterine insemination/IUI), or tubes. This bypasses any obstructions or sperm motility issues.|
|Surgical laparoscopy||Adhesions are visualized in the pelvis or abdomen with insertion of a laparoscopic tube attached to a light and monitor screen and lysed (cut). Any spots of endometriosis are cauterized (burnt) out and the tubes are made mobile.|
|Surgical hysteroscopy||A hysteroscope tube with light attached to a monitor screen views the uterine lining. Any polyps or obstructions are removed. If a septum (wall) is discovered, it is removed.|
|Tubal ligation reversal
|If the tubes were “tied” for contraception in the past, the open tube ends are joined together.|
|In vitro fertilization (IVF)||Egg and sperm are fertilized in the laboratory. The developing embryo is then inserted into the uterus. This bypasses the need to go through the fallopian tubes, which can be damaged beyond repair or absent.|